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C ase 1-G reen stick frac tu re o f the u lna w ith ex tens ion defo rm ity an d fo rw ard d isp lacem en t o fth e upper end of th e rad iu s.

F. . 2C ase 2-G reenstick frac tu re o f the u ln a w ith ex tension d efo rm ity and fo rw ard d isp lacem en t o f

the upper en d of the rad ius.

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GREEN ST ICK FRACTURE O F THE UPPER END O F TH E ULNAW ITH D ISLOCAT IO N OF TH E RAD IO -H UM ERAL JO INT ORD ISPLACEM ENT O F THE SU PER IO R RAD IAL EP IPH Y SIS

P . R . WRIGHT , M ARGATE , ENGLAND

The pu rp ose o f th is p ap er is to desc rib e an in ju ry o f ch ildho od w hich h as rece ived littlenot ice in th e lite ra tu re .

CA SE REPORTSCase 1 -A boy of fou r fe ll on to h is righ t a rm , in ju ring h is e lb ow . R ad io graphs show ed ag reenstick fractu re o f the upp er end o f the u lna w ith ex ten sion d efo rm ity , and fo rw ardd isp lacem en t o fth e upp er end o fthe rad ius (F ig . I). T he fractu re w as redu ced by m an ipu latio nu nde r gene ral an aesthesia an d the a rm w as imm obilised in p la ste r-o f-P a ris fo r fiv e w eeks.Tw o w eek s a fter rem ova l o f th e p la ste r he had rega in ed a fu ll, pa in le ss range o f m ov em en t o fth e elb ow and th e fo rearm .

C ase 2 -A gir l o f tw o fe ll from a ch a ir , in ju rin g he r le f t e lbow . R ad iog raph s show ed ag reenstick fractu re o f the u ppe r end o f the u lna w ith ex tensio n d efo rm ity , and fo rw ardd isp lacem en t o f th e up pe r en d of th e rad ius (F ig . 2 ). M an ipu lativ e reduc tio n w as pe rfo rm ed

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F IG . 3C ase 3-G reenstick frac tu re o f the u ln a w ith varus defo rm ity an d la te ra l d isp lace -m en t o f the upper end o f th e rad iu s.

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unde r gene ra l anaesthesia , and a lthou gh redu ctio n w as incom ple te th e positio n w as accep ted .Imm obilisa tion in p la ste r w as m a in ta ined fo r th ree w eek s. Tw o w eeks a fte r rem ov al o f thep laste r the ch ild had rega in ed a fu ll rang e of pa in less m ov em en t o f the e lbow and forea rm .C ase 3 -A boy o f six in ju red h is r igh t a rm w hile d o ing physica l train in g a t scho o l. H ecom p lain ed o f pa in in the e lbow , and rad iog raphs sh ow ed a greens tick frac tu re o f theupper end of the u lna w ith varus defo rm ity and late ra l d isp lacem en t o f the upper endo f the rad ius (F ig . 3 ) . T h e ex ten t o f th is in ju ry w as n o t a t firs t recog n ised and th e a rmwas imm obilised in p las te r w ith ou t m an ipu la tio n . E igh t days la ter the correc t d iagno sis w asm ade an d m an ip u la tive redu ctio n w as a ttem pted b u t w ith ou t succes s. O p en red uc tion of th eu lna r frac tu re w as th ere fo re carried o u t, and fo llow ed by fo ur w eeks im m ob ilisa tio n . A fte rthe p las ter was rem oved a fu ll rang e o ffiex ion , ex tens io n and sup ina tion w as rap id ly rega ined ,bu t p ro na tion rem a ined sligh tly lim ited (7 0 d eg rees com pared w ith 90 degrees on the o th er sid e) .

C ase 4 -A g irl o f ten fe ll d ow n a fligh t o f s tep s a t schoo l an d in ju red he r rig h t e lbow .Radiog rap hs show ed a greenstick frac tu re o f the upp er end of the u lna w ith va lg us defo rm ityand frac tu re -separa tio n o f the upper rad ia l ep iphys is (F ig . 4 ) . O pen redu c tion of theep ip hys is w as carried o u t, toge the r w ith m an ip u la tion ofthe u ln ar frac tu re, an d im m ob ilisa tionill p las ter w as m ain ta ined fo r th ree w eeks. O n rem ov a l o f th e p las te r it b ecam e c lea r th a tredu ction of th e u lnar frac tu re w as incom p lete and th at th ere w as abou t 1 5 deg rees o f cub itusv a lg us. Th is pos ition w as accep ted . F lex io n an d ex tens ion of the e lb ow rap id ly re tu rn ed ton orm al bu t p rona tion and su p ina tio n rem ained lim ited . F urthe r rad io graphs fo ur m onthsa fte r in ju ry show ed tha t the u lnar f ractu re invo lved the su perio r rad io -u lnar jo in t (F ig . 5) ,and th is exp lain ed a gradua lly dec reasing range of p ro na tion and sup in atio n . E igh teenmon ths a fte r in ju ry ante rior tra lispO sition o f the u lnar nerv e w as perfo rm ed in v iew of th ecu b itu s va lgus . T h irty m onths a fte r in ju ry flex ion and ex tens io n rem ain ed a lm o st fu ll, bu tsu p ina tion an d p ro na tion w ere absen t, the fo rea rm be ing fix ed a t 4 5 degrees o f sup in atio n .Radiograph s sugg es ted th a t fu sion of the sup erio r rad io -u lnar jo in t had tak en p lace (F ig . 6 ).C ase 5-A boy of th irteen su stain ed an in ju ry to h is le f t elb ow , the de tails o f w h ich w ereunknown. R ad io grap hs sh ow ed a green stick frac tu re o fthe up pe r end o fth e u lna w ith va lgusdefo rmity an d a frac tu re -separa tion of th e u pper rad ial ep iph ysis . T here w as a lso separa tionof the ep ip hysis o f the m ed ia l hum era l ep icon dy le . T rea tm en t w as b y m an ipu la tion und erg ene ra l anaesthesia fo llow ed by th ree w eek s imm obilisa tion in p la ste r. T he po sition o nrem ova l o f th e p laste r is shown in F igu re 7 . R ecov ery of m ovem ent o f the e lb ow and fo rearm

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F IG . 4Ca se 4 -G reen stick fr actu r e o f th e u ln a w ith va lgu s d e form ity a nd fr actu r e-

separa tio n o f the u pper rad ia l ep ip hys is .

F IG . 5

FIG . 6

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VOL . 45 B, NO . 4, NOVEMBER 1963

Case 4-R ad iog raphs afte r a ttem p ted reduc tion , show ing incom ple te red uc tio nand in vo lvem en t o f the superio r rad io -u ln ar jo in t by th e u ln ar frac tu re .

C ase 4 -R ad iog rap h s tak en th ir ty m on th s a fter in ju ry sug ges tin g fu s ion o f th esuperio r rad io -u ln ar jo in t.

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C ase 5-R ad iograp hs afte r reduc tion .

rr. , I, _#

L . I

Case 5-R ad iograph s show ing un ion of the u lnar f ractu re w itho u t invo lvem en to f the superio r rad io -u lnar jo in t.

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was s low and four m on th s a fter in ju ry th ere w as still 3 0 degrees loss o f ex tens ion and 40 degreeslo ss o f flex io n . P ro na tion w as lim ited to 20 degrees and su p ina tion to 70 degrees . A t th istim e it becam e clea r tha t traum a tic u ln ar n eu ritis w as deve lop ing and an te rio r transpo sitionof the u ln ar ne rv e w as pe rfo rm ed . F u rth er rad iog raphs sh ow ed th at the u lna r fractu re h adun ited and tha t invo lvem en t o f the su pe rio r rad io -u lna r jo in t h ad no t o ccu rred (F ig . 8 ) .

D ISCUSS IONHum e (1957) d escr ibed th ree cases o f un d isp laced frac tu re o f the o lec rano n in ch ild ren

as soc ia ted w ith an te rio r d isloca tion o f the h ead o f the rad iu s. Th e rad iog raph s in h is pape rshow ed th at in o ne of th e case s the re w as a va ru s de fo rm ity o f the u ln a at the site o f th efra ctu re and th e head o fth e rad ius w as d isp laced late rally , s im ila r to the d isp lacem en t desc r ibedin C ase 3 above .

B eddow and C orke ry (1 960 ) desc rib ed tw o cases o f th e sam e ty pe , in w hich a g reenstickfractu re o f the upp er end o f the u lna w ith va ru s de fo rm ity w as accom pan ied by la tera ld is lo ca tion o f the rad io -h um eral jo in t.

T h e lite ra tu re do es n o t con tain any o th er reports o f th is in ju ry .It seem s c lea r th at, no m atter w ha t the d irec tion of an gu la tio n o f the u lna m ay b e, the

u lna and th e rad ius rem ain in a fixed re la tion sh ip to o ne ano th er w h ile th e in ju ry is tak ingp lace. O n ly in th is w ay can the co rrespon dence b e tw een the d irec tion of ang u la tion of theu lna an d the d irec tio n of d isp lacem en t o f th e up pe r en d o f the rad ius be exp lain ed . F or thesam e reason it seem s c lear th at th is po sition m us t be on e of fu ll sup in atio n . T he m ost p ro bab lem echan ism th ere fo re seem s to b e a fa ll o n to the ou tstre tch ed hand during w hich the fo rea rmis he ld su p ina ted (as it m igh t be ifth e ch ild w ere fallin g b ackw ards) . T he d irectio n of ang u la tion

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VOL . 45 B, NO . 4, NOV EMBER 1963

o f the u lna w ill then be de te rm in ed by the ex ac t d irec tion of th e fall, w h ich m ay p ro duce avaru s, va lgus or h yperex tens io n stra in on th e fo rearm (F ig . 9 ).

Hum e (195 7) sug gested th at an te rio r d isp lacem en t o f the h ead of the rad iu s m igh t beex p la ined by a h ype rex tension strain on th e u ln a w hile the rad ius is in the positio n ofp ro na tion -a m echan ism s im ila r to tha t desc r ibed by E vans (19 49) in the p rodu c tion of theM ontegg ia frac tu re-d islo catio n . S uch an ex p lana tion , how eve r , co u ld no t app ly to those casesw ith m ed ia l and la tera l d isp lacem en t. I tseem s m ore lik ely tha t a ll th ree types fo rm agroup , in w hich th e po sition ofthe arm dur-ing the in ju ry is essen tia lly th e sam e, bu tth e d irec tion o fang u la tion is d e term ined bythe ex act d irec tion of th e fa ll.Com plica tions -l) Im perfect redu ctio n m ayresu lt from fa ilu re to reco gn ise the tru ena tu re o f the in ju ry w hen it is f irs t seen .E ven w hen it is recog n ised , th e d isp lace -m en t o f the u lna m ay no t be easy to co rrec tby m anipu la tion (C ases 2 and 4). 2 ) T rau -m atic u lna r neu ritis is a cons id e rab le dang erin tho se cases w ith va lgus d e fo rm ity ifredu ctio n is im pe rfect. 3 ) R ad ia l ne rvein ju ry w as n o t seen in th is s er ie s b u t itoccurred in one o f the pa tien ts w ith la te rald isp lacem en t o f th e rad ia l head desc ribedby B eddow and Cork ery (1960 ). T h eyconsid e red it to be a n eu rap rax ia resu ltingfrom traction by the d isp laced rad ius onthe rad ia l ne rve as it w inds th roug h the GREEN ST ICK FRACTURE OF MONTEGG IA INJURYsup ina to r m u scle . 4 ) In ju ry to the supe rio r ULNA W ITH VARUS DEFORM ITYrad io -u lna rjo in t m ust o ccu r in a ll cases b u t A ND LATER AL DISPLAC EM ENT

OF RAD IAL HEADcom ple te loss o f m ovem en t o n ly occurred F 9in on e case, in w hich the u lna r frac tu re To illu stra te the m echan ism of th is in ju ry an d theapp ea red to hav e in vo lv ed th e jo in t. M on teg g ia in ju ry .

SUMMARY1 . F ive cases o f g reenstick fractu re o f the up pe r end of th e u lna w ith d is locatio n of therad io -h um eral jo in t a re d escr ibed .2. A ltho ugh th e d irec tion o f angu latio n of the frac tu re and the co rre spon d ing d isp lacem en to f th e upp e r end of th e rad ius m ay be late ra l, m ed ia l o r an te r io r , it is sug gested tha t all fiv ecases fo rm a gro up in wh ich the m echan ism ofin ju ry is essen tia lly th e sam e. T h is m echan ismis cons id e red to be a fa ll on the ou ts tretched hand w ith the fo rea rm he ld in sup ina tion .3. T he com plica tions o f the in ju ry are d escr ibed .

I shou ld lik e to thank M r W . A . W att M aney for perm iss ion to inc lud e Ca se 5.

REFERENCESBED DOW , F . H ., and CORKERY , P . H . (1960) : L a te ra l D isloca tion of the R ad io -hum era l Jo in t w ith G reens tick

F ractu re o f th e Upper End of the U ln a. Jou rna l o f B on e a nd Jo in t Su rg ery , 42-B , 782.EVANS , E . M . (1 949): P ronat ion Injur ies o f the F orearm . Jo urn a l o fB on e an dJo in t Su rge rv, 31 -B , 578 .HUME , A . C . (1957 ): A n te rio r D isloca tion o f the H ead of the R ad ius A ssoc iated w ith U ndisp laced F rac tu re

o f the O lecrano n in C hild ren . Jou rn a l o f Bo ne and Jo in t S urg ery , 39-B , 508 .